What is the treatment for an adrenal crisis?

Treatment of Adrenal Crisis

Adrenal crisis requires immediate treatment with 100mg hydrocortisone IV bolus followed by continuous infusion of 200-300mg/24h (or 50mg every 6 hours) and rapid IV isotonic saline administration to prevent mortality. 1

Immediate Management of Adrenal Crisis

1. Initial Hydrocortisone Administration

   • Administer 100mg hydrocortisone IV bolus immediately 1
   • Follow with continuous infusion of 200mg/24h or 50mg every 6 hours until stabilized 1
   • If IV access is not immediately available, use IM route for initial dose 2

2. Fluid Resuscitation

   • Administer rapid IV isotonic saline (0.9% sodium chloride)
   • Give 1000ml within the first hour 2
   • Continue fluid resuscitation as needed based on hemodynamic status

3. Identify and Treat Precipitating Factors

   • Infections are the most common trigger (especially gastrointestinal) 3
   • Other causes include trauma, surgery, psychological stress, or medication non-adherence 4
   • Obtain appropriate cultures and start empiric antibiotics if infection is suspected

Dosing Considerations Based on Patient Characteristics

For pediatric patients, the following dosing schedule is recommended 1:

• Up to 10 kg: 2 mg/kg IV induction dose, then 25 mg/24h maintenance
• 11-20 kg: 2 mg/kg IV induction dose, then 50 mg/24h maintenance
• Over 20 kg (prepubertal): 2 mg/kg IV induction dose, then 100 mg/24h maintenance
• Over 20 kg (pubertal): 2 mg/kg IV induction dose, then 150 mg/24h maintenance

Ongoing Management After Initial Stabilization

• Continue hydrocortisone until the precipitating cause is resolved and the patient can resume oral medication 3
• Transition to oral hydrocortisone at 2-3 times the maintenance dose once the patient is stable 1
• Monitor electrolytes, particularly sodium and potassium levels, as patients with primary adrenal insufficiency often have hyponatremia and hyperkalemia 1
• Gradually taper to maintenance dose over several days as clinical condition improves

Prevention of Future Adrenal Crises

1. Patient Education - Critical for prevention 2, 4:

   • Stress dosing instructions (double or triple maintenance dose during illness)
   • Emergency injectable hydrocortisone use
   • Recognition of early warning signs of adrenal crisis

2. Emergency Preparedness:

   • Every patient should have a medical alert bracelet/card identifying adrenal insufficiency 1
   • Provide emergency kit for parenteral hydrocortisone self-administration 2
   • Ensure family members are trained in emergency injection techniques

3. Stress Dosing Guidelines 1:

   • Minor illness with fever <38°C: Double oral dose
   • Moderate illness with fever >38°C, vomiting, or diarrhea: Triple oral dose or use parenteral hydrocortisone
   • Severe illness: 100mg hydrocortisone IV/IM, then every 6 hours

Common Pitfalls in Adrenal Crisis Management

• Delayed recognition: Symptoms may be nonspecific (weakness, nausea, abdominal pain, confusion) leading to delayed diagnosis 4
• Inadequate initial dosing: Underdosing hydrocortisone in acute crisis can be fatal 5
• Failure to address volume depletion: Fluid resuscitation is as important as steroid replacement 2
• Premature discontinuation of treatment: Continue stress dosing until complete resolution of precipitating illness 1
• Overlooking mineralocorticoid replacement: In primary adrenal insufficiency, fludrocortisone may need to be adjusted once acute crisis resolves 1

Despite improvements in management, adrenal crisis continues to occur with an incidence of 5-10 adrenal crises per 100 patient years and contributes significantly to the excess mortality in patients with adrenal insufficiency 6, 2. Prompt recognition and treatment are essential to reduce morbidity and mortality from this life-threatening emergency.